Table 3 Categories and sub-categories related to Missed Nursing Care of frail older adults

MNC aggravating factors

Age-unfriendly structure

Inappropriate care environment

“This ward is not specifically for older adults. We have a lot of critically ill patients who need urgent care. Sometimes we have patients who need cardiopulmonary resuscitation (CPR). When I have a patient that sick, I do not have time to communicate with older adults and address their needs” (Nurse 5)

Management defect

“In the clinical assessment forms, there is no specific for older patients. So we cannot distinguish between frail older adults to pay special attention to them” (Nurse 4)

Discriminatory behaviors

“Usually the critically ill older adults are admitted to the terminal rooms of the ward. We put young patients in our priority, and they are admitted to the rooms near the nursing station.” (Nurse 14)

Staff’s high workload

“Frail older adults are usually ordered a syrup from MOM because of persistent constipation. If I give the patient the syrup several times a day, we do not have enough aides to help the patient go to the bathroom or change a diaper. So we do not have to give the medicine,” (Nurse 9)

Inefficient care

Weakness of interdisciplinary care

“Many frail older adults need physiotherapy, occupational therapists, or social help to get back into the community, but many of them are homeless. We actually know our patients need it, but we really can not do anything about it,” (Nurse 5)

Clinical incompetence

“Novice nurses do not know that they should follow up on the frail older adult’s medications that he is taking at home. For example, an older adult is admitted to the hospital for a fractured pelvic and does not remember his medications. The nurse forgets to track what he’s taking, so the patient does not take the blood pressure pill, blood pressure rises to 20 or 24, and he suffers a brain hemorrhage.” (Nurse 9)

Weakness in continuing education

“Most of the teaching materials are related to diseases, such as the management of hypertension, diabetes, and special diseases. As far as I know, we do not have special training for aging,” (Nurse 7)

Frailty of the older adults

Physical health issues

“They cannot manage most daily activities of life on their own and are often dependent,” (Nurse 2)

psychological health issues

“My patient had severe bleeding in her stool, but she did not tell us. She generally communicates with difficulty, she is mostly depressed.” (Nurse 15)

Weakness of social support

“Some frail older adults do not have a family caregiver to help them, and sometimes we do not come to help them. Sometimes their needs are ignored until someone like family caregiver can help them. Some of them do not have a home when they are discharged from the hospital and they stay here so the social worker can find a place,” (Nurse 2)

MNC moderating factors

Support capabilities

Supervisor’s support and supervision

“Some of our supervisors do everything they can to solve problems and keep working.” (Nurse 3)

Active family participation

“A good and active family caregiver is very good for the frail older adult. For example, he moves him, gives him food, gives him medication, helps him to the toilet or bathroom, helps him eat, gives him high-fiber food, gives the patient a sense of familiarity and trust.” (Nurse 9)

Ethical and legal requirements

Humanistic view to patient care

“Caring for the elderly reminds me of my mother, who was once in the hospital and preferred to be cleaned every day. So I force the nurse aid to bathe the frail elderly or wash their hands and face every shift” (Nurse 3)

Concerns for being accountable

“If you do not do your job properly, you will be known on the ward as someone who does not take good care of the patients. So I am careful about caring for patients, especially frail older adults and patients without family caregivers.” (Nurse 6)